INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Squirrel Hill was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records for December 2013 through November 2014 were reviewed on December 10, 2014. The facility failed to document an unannounced fire drill for December 2013.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Manager is primarily responsible to ensure that monthly fire drills are conducted and documented. With the results of this licensing visit, the Program Director has instructed the Clinical Manager to conduct and document a facility fire drill no later than the end of the third full week of each month.
The Director also has instructed the Administrative Assistant to monitor this activity by reminding the Manager of the fire drill need, if it has not been conducted by the beginning of the third week of each month.
This protocol is to go into effect immediately, as of Dec/2014.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of fourteen client records.
The findings include:
Fourteen client records were reviewed for written, informed and voluntary consents on December 10, 2014. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in client records # 4 and 5.
Client # 4 was admitted into treatment on November 10, 2014. Information contained in the client record was release to a funding entity on November 12, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 4, prior to disclosing information to the funding entity.
Client # 5 was admitted into treatment on January 8, 2014. Information contained in the client record was release to a funding entity on January 9, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 5, prior to disclosing information to the funding entity.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director instructed the Clinical Manager to:
1) discuss these findings with the Evaluation Specialist and Administrative Assistant, who are typically responsible for acquiring consents for funding sources on 12/22/2014 and review the policies/procedures for confidentiality and acquiring consents to disclose patient information with these staff members;
2) also discuss these findings in the next staff meeting (scheduled 12/23/14) and review the policies/procedures for confidentiality and acquiring consents to disclose patient information;
3) beginning 12/22/2014, with all admissions, the Administrative Assistant will complete an admission, audit review of completed consents, including assuring that appropriate consents for funding sources have been completed;
4) beginning the week of 12/22/2014, the Clinical Manager will provide oversight supervision of the Administrative Assistance's audit review in, at least, a weekly supervisory meeting.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a review and update of the treatment and rehabilitation plans at least every 60 days in three of ten outpatient client records.
The findings include:
Ten outpatient client records were reviewed on December 14, 2014. Ten client records were required to include documentation of a review and update of the treatment and rehabilitation plans at least every 60 days. The facility failed to document a review and update of the the treatment and rehabilitation plans in client records # 7, 10 and 11.
Client # 7 was admitted into treatment on February 5, 2014 and discharged on April 30, 2014. The individual treatment plan was completed on February 12, 2014. A treatment plan update was completed on April 2, 2014 and did not include a review of the client's progress in relationship to the stated treatment plan goals.
Client # 10 was admitted into treatment on October 9, 2014. The individual treatment plan was completed on October 12, 2014. A treatment plan update was completed on December 4, 2014 and did not include a review of the client's progress in relationship to the stated treatment plan goals.
Client # 11 was admitted into treatment on December 2, 2013. The individual treatment plan was completed on December 9, 2013. Treatment plan updates were due to be completed on February 9, April 9, June 9, August 9, October 9 and December 9, 2014. Treatment plan updates were completed on March 20, May 13, July 2, August 18 and October 31, 2014 and did not include a review of the client's progress in relationship to the stated treatment plan goals.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 17, 2014 and November 18, 2013 licensing inspections.
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Plan of Correction
The Clinical Manager will focus on and review the results of this licensing visit in two staff meetings on December 23, 2014 and on January 13, 2015. During these staff meetings, staff will also review the regulation which specifies that treatment plan reviews are to be conducted within 60 days of the established treatment plan.
The Clinical Manager, who assumed her position after last year's licensing visit, will develop and maintain a client treatment plan file, from which she will identify all outpatient clients' treatment plans that are due to be reviewed/updated one week prior to the due date. In turn, she will ensure that needed treatment plan reviews will be conducted prior to the scheduled end date.
The manager will provide a report of completed treatment plan and review dates on all clients to the director on a monthly basis.
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